The challenge to develop blood transfusion medicine to high standards in resource-limited countries
Faten M. Moftah, Head of Egyptian NBTS, 9 Al-Gazaer street, Mohandesin, Giza, Egypt.
Blood transfusion services have witnessed tremendous developments in the last three decades. This milestone was triggered by the AIDS pandemic in the early 1980s. These developments include technical, social, economical and financial aspects. All these developments lead to the growth and upgrade of the safety and efficacy of the blood components offered to many patients and casualties. The medical and general society has then realized the extreme importance of the blood transfusion supply both from the safety and availability aspects. Naturally this progress needed huge financial support and a strong infrastructure to meet these expenses.
A modern, efficient and robust blood transfusion services have placed a lot of financial burden on the budget of many countries. The industry in this field has taken this science to a very high level standard that placed peer pressure on health authorities of the majority of the countries. Developed countries with strong health insurance systems and well-established infrastructure have managed to accommodate these budgets. Countries with limited resources faced a huge challenge to meet this pressure of providing the same safety and efficacy that is required to their nations. These challenges included the provision of infrastructure, funds, transfer of know how, insuring relevant HR, and procurement logistics.
Egypt as a model of developing countries with limited resources has gone through a very tough experience during the last decade to establish a well-organized blood transfusion services. BTS in Egypt started since 1948 in Alexandria when the first blood bank was established by the Red Crescent Society. Soon after the hospital-based blood banks grew up in number until they reached around three hundred scattered all over Egypt by late 1990s. The fragmented blood system leads to poor quality, unavailability most of the time, presence of professional blood donors, and unstandardized practice. In 1996, ministry of Health in Egypt sought the help of the Swiss government to conduct a project between the two countries titled restructuring of the blood services in Egyptian MoH. The project aims at
- 1 Reorganization of the existing hospital-based system to become regionalized service.
- 2 Creating national blood policy, plan, standards and guidelines.
- 3 Phasing out the family replacement blood donors to be replaced by Voluntary Non-Remunerated Blood Donors.
- 4 Establishing a network of regional blood centres in all the Egyptian governorates to be the sole provider of blood and blood components.
- 5 Converting all the existing hospital blood banks in the different categories of hospitals into storage facilities.
- 6 Implementing a national comprehensive quality system, audit program and hemovigilance.
- 7 Implementing the concept and practice of Appropriate Clinical Use of Blood.
- 8 Implementing a blood management system using robust software, hardware, and networking to handle the huge increase in the blood collection and processing.
- 9 Establishing a national blood regulatory authority.
- 10 Developing the human resource by a relevant training program which was called the technical assistance program.
The project was designed to be executed in two phases during the period from 1997 to 2011. The first phase aimed at establishing nine centres in nine governorates. After the accomplishment of the first phase, it was realized that this network of blood centres added an extra stakeholder on top of the existing ones. The second phase aimed at establishing 15 other centres in the rest of the governorates. The second phase was designed to complement the first one to achieve the original objectives. It was decided to have a network of a national centre and twenty-three regional centres to be able to serve all the country, and convert the blood banks in hospitals in a timely plan. Many challenges have faced the project implementation unit (PIU) as follows;
- 1 Reasonable sustainable funds.
- 2 Human Resource development, both in numbers and capacity.
- 3 Acceptance by health authorities, personnel and society. All of the stakeholders resisted the anticipated change because of fear of loss of control and power.
- 4 Enforcing the policy and standards to be used and implemented by the health institutions.
- 5 Mobilizing the community to become regular Voluntary Non-Remunerated Blood Donors.
- 6 Educating the nursing, clinical and medical staff to follow the national Appropriate Clinical Use of Blood guidelines.
- 7 Resistance by other health sectors inside Ministry of Health, e.g. local health authorities in some governorates, directorate general of hospitals, etc.
- 8 Changing the concepts and cultures of the society towards the centralization of blood production and separating the provider of the service from its users.
The managing team handled these challenges in a professional way, which needed a lot of patience, advocacy, evidence based results, and consistency. The implementation plan had to be modified and reiterated several times.
The project implementation team decided to start the plan in one governorate as a pilot model. The most difficult governorate was chosen to have the chance of experimenting all the problems and try to come up with suitable solutions. The implementation of the pilot was planned in 6 months; eventually it lasted for eighteen months. The pilot was indeed a success story, the conversion plan was implemented and only one blood centre provided quality blood products to the hospitals and the HBBs staff were satisfied at last.
Results and conclusion
In 12 years the National Blood Transfusion Service of Ministry of Health in Egypt has become a model in the Middle East for a strong organization in spite of the previously mentioned challenges and the other underdeveloped health aspects in the same country. The National Blood Transfusion Service has successfully implemented a plan that lead to one organization for blood provision in the Ministry of Health institutions. The main two challenges that are facing this organization at the moment; the Information Technology project which will provide the service with the appropriate blood management system, and the provision of enough blood supply because of sluggish national blood donor program. These two challenges are being handled seriously by the NBTS and MOH, promising preliminary results are coming up.
Limited resources countries in need of a well-organized blood transfusion services are advised to follow the following recommendations;
- 1 Co-ordinate the existing blood transfusion activities and make use of existing personnel and infrastructure.
- 2 Invest in human resources by conducting relevant training and seek the help of another country, WHO, or ISBT education W/P.
- 3 Twinning program with another country for the transfer of knowhow. Make sure to acquire robust technologies and applications.
- 4 Learn from other similar conditions that developed successful services. Avoid repeating same mistakes and look for what is suitable to the local conditions.
- 5 Gain suitable, powerful and sustainable political support. Media can be helpful with appropriate information.
- 6 Mobilize the different resources (social, financial, political, etc.) existing in the country. NGOs, businessmen, and celebrities can play a crucial role.
- 7 Follow a well-designed plan. Simple, realistic, and achievable plans can provide credibility.